Photo credit: Allan Gichigi / Save the Children

Guidance
SAFEGUARDING CHILDREN IN OUR HEALTH
WORK
February 2019
Guidance
Safeguarding Children
In our HEALTH work
The provision of basic, lifesaving, maternal newborn and
child healthcare to communities is a key part of Save the
Children’s work in emergencies, as is communicable disease
prevention and control, and sexual and reproductive health.
Improperly run health clinics, mobile clinics, vaccination
campaigns, outreach or other health interventions can result
in allow abuses to occur, or fail to prevent accidental harm
to children and their families. Health facilities and mobile
clinics can also be locations for sexual exploitation and
abuse of children, perpetrated by our staff, partners, and
community members.
The physical nature of clinical work (children being touched
by adults) increases the opportunity for abuse (adults
touching children). The need for children to be separated
from their caregivers, and potentially isolated, also increases
their vulnerability and potential exposure to abuse.
In addition to all this - chaotic humanitarian contexts with
high staff turnover and high stress results in the
opportunities for abuse to be increased, and all staff need to
be acutely aware of this, in order to safeguard children.
This document will outline some potential child safeguarding
risks of our health programmes, and give you suggestions on
how to manage them to ensure children are as safe as
possible. It is not an exhaustive list, but may help you think
through a good risk management strategy.
Common types of harm & abuse in health
programming
Physical & sexual abuse
Exploitation
Emotional abuse or bullying
Unsafe programming
Key things to remember
1. Eliminating opportunities for children to have
isolated 1:1 time with medical staff, partners and
volunteers will dramatically reduce the likelihood
of sexual abuse and exploitation occurring
2. There will be an unequal power dynamic
between children and their caregivers who
urgently need access to healthcare, and staff and
partners who work in health facilities
3. Allowing adults and child patients to remain on
the same ward overnight is high risk for sexual
abuse – staff patrols must be in place
4. If frontline staff (e.g. midwives, nurses, doctors)
are not trained to ask questions about potential
sexual assault, abuse or exploitation they may
miss the signs of abuse or cause harm by
handling the case badly
5. Risk management is an active, on-going
process that never stops! Don’t be afraid to
challenge each other to ensure children are
safeguarded.
Possible ‘people’ risks
• Women and girls in the community may be unwilling to
visit a health programme site if it means they will be
alone with a man or men (e.g. in the waiting room, or
they will be seen by a male doctor). Equally, in some
places women may be unable to make decisions
regarding health care without men in their family present
• An unequal power dynamic between children and their
caregivers who urgently need access to healthcare, and
NGO staff and partners who work in health facilities
(possibility of sexual exploitation, especially sex-for-
medicine)
• Children who are left alone with doctors or other health
staff; and under guise of an examination, may be harmed
– for example, sexual abuse can occur
• Untrained health staff and volunteers who do not
understand the risks of unsafe health programming; who
are willing to ‘cut corners’ in an emergency, or who do
not prioritise the welfare and wellbeing of children
• Allowing adult and child patients to remain on the same
ward overnight is extremely high risk for sexual abuse
and should be avoided wherever possible; if unavoidable
waking staff should patrol the wards at night
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Guidance

• Caregivers may wish to remain with their children

overnight and in some cases this can reduce risk (for EXAMPLE: A 13 year old girl named Promise
example, if there are low staffing levels and a patrol is arrives at a primary healthcare centre run by Save
not possible), however, this should be carefully balanced the Children. She has abdominal pain and bruising.
against the risk posed by the caregiver to other children The male doctor examines her, and asks if she has
been spending time “loving her boyfriend” and tells
• Peer-on-peer abuse is also a risk; this risk is increased her that her family will be angry at her. Promise
where children of very different ages are left to mix feels ashamed, thinks she is to blame, and runs
unsupervised, for example overnight on a ward. In some away from the clinic. She never tells anyone that
places this can also be exacerbated due to ethnic/ she is being raped by her Uncle.
clan/tribal tensions which may lead to abusive behaviour
• Untrained, unsupported or unsupervised community
mobilisers and volunteers can pose a risk to children –
both through accidental harm and deliberate abuse (for • If survivors of sexual violence are supported or referred
example: providing inappropriate advice, use of physical through the health programme, there is a significant risk
violence to discipline children, expecting sexual favours in that the health staff who examine them may verbally
return for health services) shame, belittle or blame the survivor for their own
assault, or that their surroundings trigger feelings of
• Untrained healthcare workers and support staff may helplessness or pain. This may result in a survivor
respond inappropriately to survivors of sexual violence deciding not to report their assault to the Police; or not
(for example: verbally shaming, belittling or blaming the seeking any further help.
survivor for the assault) or acting in a way that re-
traumatises the survivor. This may result in a survivor • An unequal power dynamic between recipients of
not seeking appropriate healthcare and/or choosing not healthcare (children and their families) and healthcare
to report the abuse to the authorities workers and other support staff may increase the risk of
exploitation (for example: sex-for-medicine)
• Staff who think that no-one will report them, or think
that children will not know their name are more likely to • Untrained staff maybe unaware of the importance of
use physical violence to discipline children (for example informed consent
telling children to leave a certain area of a clinic), and • Unaccompanied children may lack capacity to give
may be more likely to abuse children in other ways informed consent
• Children may arrive alone and unaccompanied at the
clinic or health programme site. These children must be
carefully looked after, both in terms of their health needs
and their rights regarding their treatment and how to
ensure informed consent to treatment.
• Medical staff, volunteers, other adults (including
caregivers) may be experiencing trauma themselves
(esp. in conflict response); and may need extra support
to better help child patients
• Health facilities may be seen as appropriate site for
parents and carers to abandon children, particularly
babies, that they feel unable or unwilling to care for;
these children will be particularly vulnerable, with the
potential higher risk of illness due to malnutrition and
Photo credit: Fredrik Lerneryd / Save the Children
neglect, previous abortion attempts by the mother and
community stigmatisation

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Guidance
How can we manage these risks?
• Consult with local healthcare workers and key
community stakeholders to help identify community
practices and beliefs that may impact on the local
community’s acceptance and utilisation of health services
• Ensure that the local community (including boys and
girls, women and men) are consulted in a meaningful
way on the health programme; from the design phase
onwards; and given regular opportunities to feedback on
any concerns
• Ensure a waking staff presence 24hrs a day on all in-
patient wards; and that they regularly patrol or
monitor the wards during the night
• Try to ensure a gender balance in staffing, with
appropriately trained staff to deal with the expected
population needs; when gender appropriate healthcare
staff are not available try to offer gender appropriate
advocates who can support the patient and chaperone
consultations
• Ensure clinicians recognize the signs and symptoms of
abuse (physical, sexual and emotional), and that all staff
and partners are briefed on the basics of SGBV; and
understand how to approach survivors in a
compassionate, careful way
Photo credit: Saman Saidi / Save the Children
• Wards/inpatient accommodation should be provided for
families, single women, single men and unaccompanied
children (with separation of adolescent girls and boys).
However, separation of individuals from their social
supports should be done with sensitivity to both their
social support needs and the potential risks of
exploitation, e.g. by providing separate accommodation
but communal living during the day
• Ensure that all staff, volunteers, and visitors to the health
programme site sign in and out; and that the exits and
entrances are carefully monitored
• Consider separate waiting areas (male/female)
• Employ female health staff members with skills and
experience working with women
• Ensure that boys and girls, women and men are
consulted in a meaningful way on the health programme
from the design phase onwards. Give people regular
opportunities to feedback on any concerns.
• Install an anonymous feedback mechanism to learn
about accessibility, safety, and security related to
services and facilities and to identify any safeguarding
risks.
• Ensure that no child is left alone with a member of staff
or a volunteer – remember the ‘two adult rule’. If
examining a child, a chaperone must be present in the
room.
• Support children, adults and medical and support staff
supporting children and adults to develop coping
mechanisms to deal with trauma, for example by
engaging children and adults in mindfulness exercises
• Ensure all staff, volunteers and other representatives are
trained and engaged on child safeguarding and
understand the importance. Spend additional time with
your frontline staff (e.g midwifes) on the importance of
spotting and responding to potential abuse.
• Where feasible, clearly demarcated and clearly
communicated wards for boys and girls, women and
men; consider colour coding areas for clarity – so it is
immediately obvious if someone is somewhere that they
shouldn’t be. This will not be possible in all health
settings.
• Reduce anonymity – always wear a Save the Children t-
shirt when working; unless staff are in a health
environments in which there are particular uniform
expectations and hygiene imperatives which may make
Save t-shirts inappropriate e.g. use of scrubs.
• Challenge staff members alone, or seeking to be alone,
with children.
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Guidance
Informed consent in healthcare
settings:
For consent to be valid, it must be voluntary and informed,
and the person consenting must have the capacity to make
the decision.
• voluntary – the decision to either consent or not to
consent to treatment must be made by the person
themselves, and must not be influenced by pressure
from healthcare workers, friends or family
• informed – the person must be given all of the
information in terms of what the treatment involves,
including the benefits and risks, whether there are
reasonable alternative treatments, and what will
happen if treatment doesn't go ahead
• capacity – the person must be capable of giving
consent, which means they understand the information
given to them and they can use it to make an informed
decision; in the case of children giving consent
Informed consent for children:
Consent can be obtained from children if the clinical staff are
satisfied that they have enough capacity, intelligence and
understanding to fully comprehend their treatment. If clinical
staff are not satisfied that a child has sufficient capacity to
understand, caregivers/parents should give consent.
In a situation where treatment is vital and waiting to obtain
parental/carer consent would place the child at risk,
treatment can proceed without consent.
All treatment should be explained to children in their local
language to ensure complete understanding. No decisions
about the child’s treatment should be made in isolation of the
child.
All patients or recognised caregivers/parents should sign
a consent form before treatment is given.
• Support staff wellbeing and reduce stress to a
manageable level – stressed, under pressure staff may
not notice risky behaviour or risk factors
• Child protection mechanisms should be in-place to
support unaccompanied children
Train healthcare staff in the importance of
informed consent, and how to access capacity to
give informed consent (see box on left!)
• Ensure that staff are trained to work with individuals
with intellectual disabilities and mental health issues,
including on how to ensure proper confidentiality and
informed consent.
• Train and engage staff and community members
responsible for physical locations on spotting the signs of
abuse, and how to report concerns (and reassure that
it’s safe to do so) – drivers, guards, cleaners, caretakers,
distribution manager, camp leader, local elders, religious
leaders
• An area dedicated to child wellbeing (for example, a
Child Friendly Space) should be set up in hospitals, and
this can also display simple child safeguarding materials,
including a display of children’s rights, in appropriate
languages
Programme & process risks
• Significant time pressures on the building of physical
structures (for example: latrines) may increase risk
through failure to adhere to health and safety processes
during construction and/or poor quality or incomplete
work
• Health programming carried out through partners or
funding external health projects, leading to lower levels
of oversight
• Poor maintenance or damage to cold chain storage; or
failure to utilise equipment appropriately
• Medications and medical supplies can unintentionally
harm children if taken improperly or inadequate
instructions provided – for example, we may think we
are helping by distributing aqua tabs to provide clean
water, but these can be very harmful if not used properly
• Not setting up robust referral processes to ensure that
survivors of SGBV are prioritised
• High risk, health facilities such as an Ebola Treatment
Centre carry unique and high levels of associated risks
and will therefore require a separate risk assessment and
management plan
• If any Health/WASH infrastructure has been damaged,
destroyed or poorly maintained, this can increase the
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Guidance
risk of contamination in health facilities and other
locations
• Informed consent for media/communications work is
difficult to achieve in health settings, as there is a clear
power dynamic – i.e Save the Children may be providing
life-saving care, so patients feel they must agree to be
interviewed or photographed. This can result in a great
deal of emotional and physical harm to children,
especially if the topic is sensitive, traumatic or
controversial
• Ensure that an information sharing protocol is
established so that a survivor of abuse will not need to
repeat their story, potentially exposing them to further
trauma; and all efforts are made to ensure his or her
confidentiality (but do not promise to keep secrets – you
will need to tell someone who can help)
• Handling of medicines and vaccines that require cold
chain storage or similar increases the risk profile of the
intervention
• If the response includes movement of people (e.g.
ambulance service, or use of pooled taxis as an
ambulance service) this increases both risk of death or
injury in road traffic accidents and driver abuse of very
vulnerable children
• Staff on health sites (e.g. guards, cleaners) do not
understand positive discipline techniques and instead use
physical and humiliating punishment to deter children
from playing on or near the site
Photo credit: Kristiana Marton / Save the Children
• If sites for health facilities do not take into account the
risk of sexual exploitation and abuse while walking
to/from the site; children and adults can both be at
increased risk of assault
• If robust referral processes to ensure that survivors of
SGBV are prioritised are not in place, survivors can be
made even more vulnerable; and may not seek help
again
How can we manage these risks?
• Provide information about services and where to raise
any concerns, in both verbal and written form, ensure
local languages are used, and contextually appropriate
images.
• Clearly state and re-state organisational rules (the Child
Safeguarding Policy, the Code of Conduct) that govern
behaviour
EXAMPLE: Save the Children is running a clinic for the
treatment of people living with HIV. One day a conflict
breaks out nearby and the clinic and all staff are evacuated.
An armed militia takes over the clinic, uses it as a base and
easily finds detailed information about people living with
HIV and survivors of sexual violence, including their
addresses. The data has not been secured. They use the
information to shame the patients into leaving the villages,
and the patients are exposed to extreme levels of abuse.
• Ensure that staff are trained to work with individuals
with intellectual disabilities and mental illnesses, including
on how to ensure proper confidentiality and informed
consent.
• Staff should be trained and capable of providing
psychosocial support to reduce trauma. If staff are not
trained, they should have the information to refer
patients to these services.
• Staff should ensure the confidentiality of survivors and
respect the wishes about the care provided.
EXAMPLE: a team member from the media team is visiting
a Save the Children clinic in the middle of an emergency.
She interviews children who are recovering from cholera.
The children are extremely weak but agree to be
interviewed. When the children leave the clinic, they are
scared to find their image on the TV, linked to a western
NGO. In their culture, this is dangerous. Their parents are
very angry with Save the Children, beat their children for
being filmed, and vow never to go back to the clinic.
• Ensure appropriate reporting structures in place for
actual or suspected incidence of abuse or harm to
children, including ‘near miss’ events
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Guidance

• Train health staff to identify and respond to traditional

harmful practices (for example, FGM, early child
marriage)
• Set up referral networks for services required in response
to instances of abuse and exploitation in line with best
practice.
• Consider the use of taxis for transport to/from health
sites; and ensure that all drivers are trained on child
safeguarding and appropriate behaviour – ensure that
children are not transported alone, without another
adult
• Work with local traditional healers to improve access to
services and also to ensure that children and
communities are aware of the behaviour they can expect Photo credit: Save the Children
from NGO workers, and how to share any concerns that
they have Risks in the physical space
• Do not use plastic bags to give medicine to young • Proximity to threats such as building sites, water, traffic,
children (risk of suffocation by small children) limited shade, unexploded ordinance
• Post clear instructions on sharing feedback in health • Cross-infection if children are hospitalized within the
programme sites, in local languages, supported by same facility as other children with infectious diseases.
illustrations
• Any areas within clinics or intervention sites which are
• Regular child safeguarding briefings on site with the isolated, obstructed or poorly supervised (could be used
health team, partners and any volunteers, vet any for abuse), including showers, latrines
contractors, and work with contractors to create a code
• Ambulance condition – risk of accidents, injury or death
of conduct
on the road due to poor equipment; or drowning if a
• Do not allow comms and media work to occur in boat ambulance is in use
sensitive health settings; unless approval has been given
• Unmonitored or uncontrolled access by adults (staff and
by Child Protection and/or Child Safeguarding
others) to clinics or site
colleagues. Always get informed consent from a
caregiver as well as the child. • Lack of appropriate areas for examination and history
taking, which may lead breaches of privacy and
• Create a daily tracker that all staff and volunteers
confidentiality (for example: curtains and screens can
should sign in to access the health facility or site.
provide physical privacy but will not prevent
• Give all health staff and contractors regular conversations being overheard)
opportunities to report concerns, without fear of losing
• The healthcare environment may also trigger feelings of
their jobs
helplessness or pain.
• Robust contract management with clear expectations
• Any site left unsupervised by staff that could be used as a
around child safeguarding and child safety for
location for abuse or that might attract both children
contractors (e.g. construction of health sites)
and adults (e.g. a hospital tent with a TV)
• Clearly state and re-state organisational rules (the Child
• Unsafe or poor quality materials used for equipment (e.g.
Safeguarding Policy, the Code of Conduct) that govern
weighing equipment, bed that allow children to roll out in
behaviour
the night)
• Clear display of child and community-friendly reporting
• Poor maintenance or build of clinics and other sites; for
mechanisms at all health programme sites
example where toilets have been built some distance
• When considering your exit strategy, ensure that from clinics or programme sites
responsible actors and child-focused systems are in place

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Guidance

• Lack of shelter and clean drinking water for mothers and • If some individuals cannot access the services, ensure
children having to wait for treatment that special arrangements are made to make them
available (e.g. mobile health teams).
• Unmanaged or risky WASH construction site as part of
the health site (e.g. half-finished latrines left uncovered • Increase the ‘natural surveillance’ of the staff in the
overnight or unguarded, or pits that have insufficient or hospital – for example by ensuring that nurses, sitting at
easily removable covers) their desk, can see into each ward and entrance/exits.
This helps to prevent abuse by reducing unsupervised
• Dangerous medicines or vaccines that can be accessed
areas
by children
• If you are operating boat ambulances; ensure that staff
• Unmonitored or uncontrolled access by adults (staff and
operating the ambulance can swim; and that floatation
others) to WASH facilities can increase the risk of sexual
devices are included within the kit for the boat
exploitation and abuse
• Review layout of clinic area and identify and mitigate
• Proximity of health facilities to armed actors (including
areas of risk (especially to be areas that are
militias, police forces, armed guards) can increase
private/lockable) with good lighting and by restricting
protection risks
access.
• WASH facilities in the health site that are not separated
for children and adults, boys and girls can – increases
risk of abuse
• Poor vehicle maintenance will increase the risk of
accidents, injury or death on the road due to poor
equipment; or drowning if a boat ambulance is in use
• Unsafe or poor-quality materials used for equipment (for
example; weighing equipment, beds that allow children to
roll out in the night)

How can we manage these risks?

• Identify areas in and around the clinic that could be
potentially unsafe like dark alleys, proximity to the bush
and mount lights or place security around them.
• Consider installing lights near health centres, if lighting is
not possible consider alternatives such as providing
torches
• Ensure that the location of health facilities and routes to
them are away from actual or potential threats such as
violence; especially the risk or threat of gender-based
violence, and attacks from armed groups. It is important
to consult the community and potential beneficiaries
about their preferences.
• Discuss with all representative samples of society (e.g.
men, women, girls, boys, the elderly, ethnic groups,
persons with disabilities) that should have access to the
services.
• Consider how seasonal environmental conditions can
prevent access to secondary health care centres and
hospitals (e.g. floods, landslides). Ensure transport
mechanisms are in place to make access possible in
different conditions.
Photo credit: Mohammed Awadh / Save the Children
• If running a hospital or clinic that may deal with
survivors of torture, special consideration must be given
to the design of rooms, type of furnishings and equipment
etc. that are in the examination/consultation rooms. This
should be considered in design phase, and should be
designed to avoid possibility of re-traumatization.
• If the clinic or health site may support survivors of sexual
violence, ensure that the patients can maintain
confidentiality
• Ensure that the location of health facilities and routes to
them are away from actual or potential threats such as
violence; especially the risk or threat of gender based
violence, and attacks from armed groups.
• Physically separate and label the latrines “male” &
“female”. Have separate latrine/toilets for males and
females, boys and girls and make sure they are labelled
clearly for all literacy levels.
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Guidance

• Ensure latrine design accounts for children (e.g. size of • Ensure that the locations of WASH facilities within health
pits may present a safety risk for children) sites are safe, well-lit and secured by a secondary
enclosure to ensure privacy (e.g. adequate and separate
• Ensure examination rooms are well separated from
space for women/girls, people with disabilities)
public spaces or the waiting area.
• Socket outlets and wiring are at least five metres away
• If separate rooms cannot be provided, consider
from running water outlets
establishing a dry-wall or at least put up a curtain.
• Identify areas in and around the clinic that could be
potentially unsafe like dark alleys, proximity to the bush
and mount lights or place security around them.
• Consider installing lights near health centres, especially if
lighting is not possible, consider alternatives such as
providing torches for each household.
• To reduce the risk of cross-contamination, consider using
red and green ‘zones’ to reduce this risk – painting the
walls of the zones and getting staff active in those zones
to wear the same colour
• Ensure the facilities are safe and covered – consider the
risk posed from both the sun and any rain/landslides
(especially in rainy season) Photo credit: Ellery Lamm / Save the Children

• Ensure latrine design accounts for children (e.g. size of

pits may present a safety risk for children)
• Always cover water tanks and partially built latrines
Data protection risks
near the health site – anything with a danger of children • Poor data management structures or processes – could
falling or drowning in. Remember that communities may lead to re-victimisation or stigmatisation; especially in
try to remove covers, especially if they need material to sensitive cases (e.g. SGBV, HIV)
repair homes, so make sure it’s not easily removable
• Sharing of sensitive identifiable information without the
• Ensure that the locations of WASH facilities within health consent of the beneficiary (e.g. names, addresses, or
sites are safe, well-lit and secured by a secondary traits and characteristics about the case) can lead to
enclosure to ensure privacy (e.g. adequate and separate identification, and stigma or other repercussions
space for women/girls, people with disabilities)
• Remember that information about SGBV incidents is
• services we provide. If necessary, adapt the location to extremely sensitive and confidential. The inappropriate
reduce the distance and to ensure that the most sharing of any information about any incident can have
vulnerable/marginalized have access. Consider how serious and potentially life threatening consequences for
seasonal environmental conditions can prevent access to the children and adults involved, including those helping
secondary health care centres and hospitals (e.g. floods, the child.
landslides). Ensure transport mechanisms are in place to
• Data can be stolen, or taken from health facilities, for
make access possible in different conditions.
example during a conflict.
• If some individuals cannot access the services, ensure
that special arrangements are made to make them
available (e.g. mobile health teams).
• Always cover water tanks and partially built latrines
near the health site – anything with a danger of children
falling or drowning in. Remember that communities may
try to remove covers, especially if they need material to
repair homes, so make sure it’s not easily removable

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Guidance

How can we manage these risks?

For more info or to feedback on this briefing:
• Ensure all staff members have completed the mandatory Cat.Carter@savethechildren.org or
data protection training Rachael.Cummings@savethechildren.org.uk
• Do not share identifiable information unless consent has
been given by the beneficiary (e.g. names, addresses, or
For Child Safeguarding support, please contact:
traits and characteristics about the case that can lead
to identification, etc.). Middle East: Mubarak Maman (MEEE Regional Child
Safeguarding Director)
• If requesting consent to collect and use data, make sure
Mubarak.Maman@savethechildren.org
it is properly informed and that the beneficiary has the
capacity to give consent (e.g. children or persons with West & Central Africa: Ma-Luschka Colindres (WCA
intellectual disabilities may give consent without fully Regional Child Safeguarding Director) Ma-
understanding or having the capacity to do so) Luschka.Colindres@savethechildren.org
• Do not share identifiable information unless consent has Asia: Menaca Calyaneratne (Asia Regional Child
been given by the beneficiary (e.g. names, addresses, or Safeguarding Director)
traits and characteristics about the case that can lead Menaca.Calyaneratne@savethechildren.org
to identification, etc.).
East & Southern Africa: Latha Caleb (ESA Regional
• If requesting consent to collect and use data, make sure Child Safeguarding Director)
it is properly informed and that the beneficiary has the Latha.Caleb@savethechildren.org
capacity to give consent (e.g. children or persons with
Latin America & Caribbean: Abdiel Cabrera (LAC
intellectual disabilities may give consent without fully
Regional Child Safeguarding Coordinator)
understanding or having the capacity to do so)
Abdiel.Cabrera@savethechildren.org
• Make all staff aware that they should only collect
Global level: Susan Grant (International Child
information that is needed to contribute towards
Safeguarding Director)
promoting the well-being of the individual
Susan.Grant@savethechildren.org
• Be open and honest with the person (and/or their family
where appropriate) at the outset about why, what, how
and with whom information will, or could be shared,
and seek their agreement, unless it is unsafe or
inappropriate to do so. Where anonymised data is
shared (for example, to desegregate beneficiary
statistics) there is no requirement for individual consent
• Make sure that data storage is secure and that
contingency plans are in place to secure, move or
destroy the data in the event that the area must be
evacuated.